• Note 1: Payment allowance limits subject to the ASP methodology are based on Jul 2019 (3nd Quarter) ASP data.
  • Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate whether Medicare covers a drug. These determinations shall be made by the local Medicare contractor processing the claim.
Page 2 * Effective January 1, 2020 through March 31, 2020
HCPCS Code Code Dosage Payment
Limit
Vaccine AWP % Vaccine Limit Infusion AWP % DME infusion limit Blood AWP % Blood limit Clotting factor Note
J0256 - Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg 10 MG 4.451 - - - - - -
J0257 - Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg 10 MG 4.855 - - - - - -
J0278 - Injection, amikacin sulfate, 100 mg 100 MG 1.276 - - - - - -
J0280 - Injection, aminophyllin, up to 250 mg 250 MG 10.533 - - - - - -
J0285 - Injection, amphotericin b, 50 mg 50 MG 38.077 - - - - - -
J0287 - Injection, amphotericin b lipid complex, 10 mg 10 MG 9.058 - - - - - -
J0289 - Injection, amphotericin b liposome, 10 mg 10 MG 26.726 - - - - - -
J0290 - Injection, ampicillin sodium, 500 mg 500 MG 0.98 - - - - - -
J0295 - Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5 GM 2.577 - - - - - -
J0348 - Injection, anidulafungin, 1 mg 1 MG 0.524 - - - - - -
J0360 - Injection, hydralazine hcl, up to 20 mg 20 MG 3.751 - - - - - -
J0401 - Injection, aripiprazole, extended release, 1 mg 1 MG 5.702 - - - - - -
J0456 - Injection, azithromycin, 500 mg 500 MG 2.599 - - - - - -
J0461 - Injection, atropine sulfate, 0.01 mg 0.01 MG 0.079 - - - - - -
J0470 - Injection, dimercaprol, per 100 mg 100 MG 54.761 - - - - - -
J0475 - Injection, baclofen, 10 mg 10 MG 173.6 - - - - - -
J0476 - Injection, baclofen, 50 mcg for intrathecal trial 50 MCG 60.068 - - - - - -
J0480 - Injection, basiliximab, 20 mg 20 MG 3808.08 - - - - - -
J0485 - Injection, belatacept, 1 mg 1 MG 3.772 - - - - - -
J0490 - Injection, belimumab, 10 mg 10 MG 45.491 - - - - - -
J0500 - Injection, dicyclomine hcl, up to 20 mg 20 MG 53.323 - - - - - -
J0515 - Injection, benztropine mesylate, per 1 mg 1 MG 17.731 - - - - - -
J0517 - Injection, benralizumab, 1 mg 1 MG 170.491 - - - - - -
J0558 - Injection, penicillin g benzathine and penicillin g procaine, 100,000 units 100,000 UNITS 10.866 - - - - - -
J0561 - Injection, penicillin g benzathine, 100,000 units 100,000 UNITS 13.764 - - - - - -
* Effective January 1, 2020 through March 31, 2020

Drugs not otherwise classified - January 2020

Medicare Part B payment allowance limits for drugs not otherwise classified - Effective January 1, 2020 through March 31, 2020

Drug name Dosage Payment limit Notes
Alfentanil Hcl 500 MCG 1.269
Allopurinol Sodium 500 MG 2576.822
Aminocaproic acid 250 MG 0.282
Aztreonam 500 MG 12.497
Bumetanide 0.25 MG 0.329
Bupivacaine 1 ML 0.09
Clindamycin Phosphate 150 MG 0.8
Coagulation Factor IX, Recombinant (Ixinity) 1 IU 1.653 includes clotting factor furnishing fee
Diltiazem Hydrochloride 5 MG 0.332
Doxycycline Hyclate 100 MG 18.215
Esmolol Hydrochloride 10 MG 0.331
Famotidine 10 MG 0.394
Flumazenil 0.1 MG 0.619
Folic Acid 5 MG 2.669
Glucarpidase 10 UNITS 328.863
Glycopyrrolate injection 0.2 MG 3.065
Immune Globulin (Cutaquig) 100 MG 16.422 Added January 2020
Immune Globulin (Panzyga) 500 MG 79.528 Added January 2020
Labetalol Hcl 5 MG 0.223
Metoprolol Tartrate 1 MG 0.209
Metronidazole inj 500 MG 1.185
Nitroglycerin 5 MG 1.205
Olanzapine short acting intramuscular injection 0.5 MG 1.327
Paliperidone Palmitate (Invega Trinza) 1 MG 9.744
Pegfilgrastim-bmez (Ziextenzo)? 0.5 MG 336.941 Added January 2020
Rabies Immune Globulin (Kedrab) 150 IU 317.481 Added January 2020
Rifampin 600 MG 96.572
Sodium Chloride, Hypertonic (3% - 5% infusion) 250 CC 1.392
Sulfamethoxazole-Trimethoprim 400-80 MG 0.57
Vasopressin 20 UNITS 176.153

ASP (Average Sale Price) Drug Pricing History